NCG020869DMR SW

}
ANNUAL SUMMARY DISCHARGE MONITORING
REPORT (DMR) — STORMWATER
SUBMIT TO CENTRAL OFFICE*
General Permit No. NCG020000
Calendar Year ?© (
*Report ALL STORMWATER monitoring data on this form (include "No Flow"/"No Discharge" and Benchmark
Exceedances)from the previous calendar year to the DEQ by MARCH 1 of each year.
Certificate of Coverage No. NCG02' E' i‘[ II
Facility Name: �,,t,, , ( l c_h a ,, id P .
County. P"t 0 e
Phone Number: rot-f) a.?`i - X36 () Total no. of SDOs monitored I
Certified Laboratory , j ( Lab #
Lab#
Stormwater Discharge Outfall (SDO) No. ( VMA Outfall? Yes ❑ No IV'
Is this outfall currently in Tier 2 for any parameter? Yes ❑ No ['
Was this outfall ever in Tier 2 during the past year? Yes ❑ No V
If this outfall was in Tier 2 last year, was monthly monitoring discontinued? RECEIVE(
Yes, enough consecutive samples below benchmarks to decrease frequency ❑ JAN i
Yes, received approval from DEMLR to reduce monitoring frequency ❑ 207
No,turbidity benchmark exceedances did not require monthly monitoring ❑ CENTRAL FILES
❑ ,DWR SECT
Other ION
Upstream Downstream New
Outfall No. Total - TSS, SS, Turbidity, (U) Turbidity, (D) Turbidity, Non-polar Motor Oil
Rainfall, mg/l ml/I NTU NTU NTU O&G, mg/I Usage
inches (VMA) (gal/mo.)
Stormwater Circle Circle N/A N/A >55 gallmo
Indicate NO Benchmark Benchmark average requires
BenchmarksFcow,r 100/50 0.1 50/25/10 Water Quality Water Quality 15 TSS and Non-polar
applicable Standard applies Standard applies O&G monitoring
Date Sample :
Collected, =
mo/dd/yr ,
Permit Date 10/1/2015—9/30/2020
Last Revised 10-2-2015

4 111
Certificate of Coverage No. NCGO2 ,
Additional Outfall Attachment (make copies as needed for additional outfalls)
Stormwater Discharge Outfall (SDO) No. VMA Outfall? Yes ❑ No ❑
Is this outfall currently in Tier 2 for any parameter? Yes ❑ No ❑
Was this outfall ever in Tier 2 during the past year? Yes ❑ No ❑
If this outfall was in Tier 2 last year, was monthly monitoring discontinued?
Yes, enough consecutive samples below benchmarks to decrease frequency ❑
Yes, received approval from DEMLR to reduce monitoring frequency ❑
No,turbidity benchmark exceedances did not require monthly monitoring ❑
Other ❑
Upstream Downstream New
Total TSS, SS, Turbidity, (U) Turbidity, (D) Turbidity, Non-polar Motor Oil
Outfall No. Rainfall, mg/I mill NTU NTU NTU O&G, mg/IUsage
inches (VMA) (gal/mo.)
Circle Circle N/A N/A >55 gal/mo
Stormwater Indicate NO Benchmark Benchmark average requires
FLOW�f Water Qity Water Quality
15 _TSS and Non-polar
Benchmarks applicable 100/50 0.1 50/25/10 Standard appuallies Standard applies O&G monitoring
•
Date Sample _ -,�
S fi
Collected, - .
=' : = ` '° -44
ter
mo/dd/yr -
Permit Date 10/1/2015—9/30/2020
Last Revised 10-2-2015

Certificate of Coverage No. NCGO2 n[N 6 1
CERTIFICATION
"I certify, under penalty of law, that this document and all attachments were prepared under my direction or
supervision in accordance with a system designed to assure that qualified personnel properly gather and
evaluate the information submitted Based on my inquiry of the person or persons who manage the system, or
those persons directly responsible for gathering the information, the information submitted is, to the best of my
knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for
submitting false information, including the possibility of fines and imprisonment for knowing violations."
[Required by 40 CFR§122 22] n
Signature _�— / \
Date ( (/(-, (C7
Mail Annual Summary Stormwater DMR to the NCDEQ Central Office:
Note the address is correct–Central Files is housed in DWR(not DEMLR)
N.C. Department of Environmental Quality (DEQ)
Division of Water Resources
Attn: DWR Central Files
1617 Mail Service Center
Raleigh, NC 27699-1617
Central Files Telephone [phone]
Questions? Contact DEMLR Stormwater Permitting Staff in the Central Office at:
[phone]
Permit Date 10/1/2015–9/30/2020
Last Revised 10-2-2015